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Tight Glycemic Control and Use of Hypoglycemic Medications in Older 588 Diabetes Care Volume 38, April 2015 Carolyn T. Thorpe,1,2 Walid F. Gellad,1,3 Tight Glycemic Control and Use of Chester B. Good,1,2,3,4 Sijian Zhang,1 Xinhua Zhao,1,4 Maria Mor,1,5 and Hypoglycemic Medications in Michael J. Fine1,3 Older Veterans With Type 2 Diabetes and Comorbid Dementia Diabetes Care 2015;38:588–595 | DOI: 10.2337/dc14-0599 OBJECTIVE Older adults with diabetes and dementia are at increased risk for hypoglycemia and other adverse events associated with tight glycemic control and are unlikely to experience long-term benefits. We examined risk factors for tight glycemic control in this population and use of medications associated with a high risk of hypoglycemia in the subset with tight control. EPIDEMIOLOGY/HEALTH SERVICES RESEARCH RESEARCH DESIGN AND METHODS This retrospective cohort study of national Veterans Affairs (VA) administrative/ clinical data and Medicare claims for fiscal years (FYs) 2008–2009 included 15,880 veterans aged ‡65 years with type 2 diabetes and dementia and prescribed antidi- abetic medication. Multivariable regression analyses were used to identify socio- demographic and clinical predictors of hemoglobin A1c (HbA1c) control (tight, moderate, poor, or not monitored) and, in patients with tight control, subsequent use of medication associated with a high risk of hypoglycemia (sulfonylureas, insulin). RESULTS 1Center for Health Equity Research and Promo- Fifty-two percent of patients had tight glycemic control (HbA1c <7% [53 mmol/mol]). fi tion, Veterans Affairs Pittsburgh Healthcare Sys- Speci c comorbidities, older age, and recent weight loss were associated with tem, Pittsburgh, PA greater odds of tight versus moderate control, whereas Hispanic ethnicity and obe- 2Department of Pharmacy and Therapeutics, sity were associated with lower odds of tight control. Among tightly controlled University of Pittsburgh School of Pharmacy, Pittsburgh, PA patients, 75% used sulfonylureas and/or insulin, with higher odds in patients who 3 ‡ Division of General Internal Medicine, University were male, black, or aged 75 years; had a hospital or nursing home stay in FY2008; of Pittsburgh School of Medicine, Pittsburgh, PA or had congestive heart failure, renal failure, or peripheral vascular disease. 4Veterans Affairs Pharmacy Benefits Manage- ment, Chicago, IL CONCLUSIONS 5Department of Biostatistics, University of Pitts- Many older veterans with diabetes and dementia are at high risk for hypoglycemia burgh Graduate School of Public Health, Pitts- burgh, PA associated with intense diabetes treatment and may be candidates for deintensi- fi Corresponding author: Carolyn T. Thorpe, ctthorpe@ cation or alteration of diabetes medications. pitt.edu. Received 7 March 2014 and accepted 7 Decem- The prevalence of diabetes among adults aged $65 years is projected to increase ber 2014. dramatically by 2050 (1). Dementia affects up to 16% of diabetic patients aged $65 This article contains Supplementary Data online years and 24% aged $75 years (2,3), and evidence shows that the two conditions at http://care.diabetesjournals.org/lookup/ suppl/doi:10.2337/dc14-0599/-/DC1. share a pathophysiological link (4–6). As described in the federally mandated Na- ’ © 2015 by the American Diabetes Association. tional Plan to Address Alzheimer s Disease (7), U.S. health care is poorly situated to Readers may use this article as long as the work address the needs of older adults with dementia and common comorbidities such as is properly cited, the use is educational and not diabetes. This is evident in the two- to threefold increased odds of severe for profit, and the work is not altered. care.diabetesjournals.org Thorpe and Associates 589 hypoglycemia and preventable hospital- chlorpropamide in all patients aged FY2008 (1 October 2007) and 2)were izations in diabetic patients with comor- $65 years (20). However, sulfonylureas given two or more inpatient or outpa- bid dementia (2,8). Improving ambulatory and insulin are recommended as first- tient diagnoses for type 2 diabetes (ICD-9 care, particularly reducing known risk fac- and second-line diabetes therapies in 250.x, 250.x2) in FY2008–2009 (with first tors for hypoglycemia, in older patients the general patient population due to diagnosis in FY2008) or received an oral with coexisting diabetes and dementia is strong evidence of efficacy in lowering diabetes medication through the VA in critical, but to date, few such efforts have HbA1c, low cost, market longevity, and FY2008 (25). We then linked to Medicare been made. low risk of adverse events apart from claims and enrollment data to further re- There is growing consensus that be- hypoglycemia (17,19). As patients de- fine the sample (Fig. 1). We applied the cause of their increased risk for hypogly- velop dementia, the risk of hypoglycemia Medicare Chronic Conditions Ware- cemia and reduced potential to benefit increases and the risk-to-benefit balance house ICD-9 diagnosis code list for from tight glycemic control, older diabetic of using these agents changes, especially Alzheimer’s Disease and Related Disorders patients with dementia should avoid tight if HbA1c is tightly controlled. To our (ADRD) to both VA records and Medicare glycemic control (HbA1c ,7% [53 mmol/ knowledge, no prior studies have exam- claims to identify patients with dementia mol]) and instead pursue moderate HbA1c ined the prevalence of or risk factors for (26,27). The ICD-9 codes in this algorithm levels of 7% to ,9% (53 to ,75 mmol/ the use of medications with a high risk of include Alzheimer disease, vascular de- mol). Older individuals with dementia of- hypoglycemia in patients with dementia. mentia, and a range of other specific re- ten have other risk factors for hypoglyce- In this study, we addressed these lated disorders (see Supplementary mia, including weight loss, changes in gaps in the literature by identifying risk Table 1 for full list of diagnoses). This appetite and eating habits, and difficulty factors for tight glycemic control in definition contains only minor differen- following prescribed regimens (9–11), older veterans with dementia receiving ces from an algorithm shown to have and a reduced ability to recognize and antidiabetic medication therapy. We good sensitivity and specificity com- respond appropriately to symptoms also identified the prevalence and char- pared with a gold standard clinical de- (9,12,13). Furthermore, older patients acteristics of patients at highest poten- mentia assessment (27). Patients with dementia have an average life ex- tial risk for hypoglycemia through their without an ADRD ICD-9 code who pectancy of 2–8 years (14–16) and are use of sulfonylurea and/or insulin after filled a VA prescription for an antide- unlikely to experience benefits of tight exhibiting tight glycemic control. Such mentia medication (galantamine, riva- glycemic control, which take years to ac- data can help to inform future interven- stigmine, donepezil, memantine, or crue and are less likely in patients with tions to improve adherence to the VA tacrine) in FY2008 were also included. long-standing diabetes (11). As such, diabetes treatment guidelines and AGS Next, because veterans aged $65 years since 2003, guidelines from the U.S. Choosing Wisely guidelines recommend- are eligible to enroll in Medicare and use Departments of Veterans Affairs and De- ing against tight glycemic control in this non-VA health care in addition to VA care fense (VA/DoD) have presented a risk- population and enhance safer prescribing (yet we did not have access to non-VA stratified approach to glycemic control, for veterans with dementia previously prescription drug records), we took two recommending tight control (HbA1c shown to be at especially high risk for steps to restrict the sample to patients ,7% [53 mmol/mol]) only for patients severe hypoglycemic events (2). with diabetes managed primarily within with a life expectancy of 10–15 years or the VA: 1) eliminating all patients whose more and absent/mild microvascular RESEARCH DESIGN AND METHODS Medicare records indicated enrollment complications (17,18). The American Di- Design and Data Sources in a non-VA source of drug coverage dur- abetes Association and American Geriat- We conducted a longitudinal, retrospec- ing follow-up (i.e., Medicare Part D rics Society (AGS) subsequently adopted tive cohort study using administrative stand-alone plan, Medicare Advantage similar recommendations (19,20), with data from the VA health care system and plan, employer-sponsored plan eligible the AGS in 2013 including the avoidance Centers for Medicare & Medicaid Services. for a Centers for Medicare & Medicaid of tight glycemic control in older adults Data sources included were VA Medical Services retiree drug subsidy) and 2) ex- with comorbidities in its Choosing Wisely SAS Datasets, records of dispensed outpa- cluding all remaining patients with HbA1c campaign (21). Although others have tient prescriptions, and laboratory values levels solely monitored outside the VA, documented the elevated risk of hypo- linked to Medicare Part A, Part B, and en- indicated by no HbA1c values in VA re- glycemia in older diabetic patients with rollment data obtained for a larger study cords and at least one procedure code dementia (2), no studies to our knowl- for an HbA test in Medicare claims. (23,24). All baseline variables and HbA1c 1c edge have focused on understanding risk levels were based on fiscal year (FY) 2008 Next, to ensure accurate capture of out- factors for tight glycemic control in pa- data; the first 120 days of FY2009 served as patient medications used in the 120-day tients with comorbid dementia. the follow-up period for determining anti- follow-up period, we excluded patients Choice of antidiabetic medication also diabetic medication use. The VA Pittsburgh who died or resided in a VA or Medicare- may exacerbate risks to type 2 diabetic Healthcare System Institutional Review covered hospital or nursing home for patients with dementia, especially when Boardapprovedthisstudy. $30 days during the follow-up period HbA1c is tightly controlled (22).
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